Social determinants of health have proven and measurable impacts on the health outcomes of patient populations. This is why the healthcare industry is seeing heightened focus on SDOH from many sectors, including payer organizations, health systems and independent medical groups.

SDOH are factors influencing patient outcomes that are outside the scope of traditional medicine. These might include geographical factors such as where a patient lives, social factors like interpersonal relationships, cultural factors like religion and economic factors such as income.

Different from SDOH, and more foundational to patient health and well-being, are critical needs, such as water, food, shelter and clothing.

Value-based care on the rise

“From a population health management perspective, priority cohorts are traditionally identified based on clinical factors,” said Dr. Joseph Siemienczuk, chief medical officer at Enli Health Intelligence, a population health IT vendor.

“As value-based reimbursement increases in prevalence, health systems are inclined to better understand all attributed patients, including their social barriers that could impact health,” he said. “The case to incorporate SDOH into population health management becomes an equation of downside risk versus the cost of health investment.”

Understanding social barriers to health improvement and operationalizing those insights into the clinical workflow can better individualize a patient’s care pathway, which leads to better financial and population health outcomes, he added.

Environmental and social factors can have a major impact on a person’s health, said Dr. Tanuj Gupta, senior director and physician executive at Cerner.

“If a person doesn’t have to worry about where their next meal is coming from, they may have more time and energy to focus on nutrition,” he explained. “If a person has a car and health insurance, they may be more likely to see a doctor regularly to maintain good health.”

Populations that do not have access to nutritious food, reliable transportation, safe housing or health insurance are at a higher risk for health issues. Using social determinants of health – the conditions in the places where people live, learn, work and play that affect a wide range of health risks and outcomes – is about preventing people from getting sick and optimizing positive outcomes when they are sick.

Hierarchy of needs

When it comes to population health, it’s not enough to just understand the medical issues that affect a patient – one must consider the whole person, contended LeRoy Jones, founder and CEO of GSI Health, a population health IT vendor.

“People tend to rationalize social determinants of health first in their hierarchy of needs, so if people are worried about where they’re going to sleep, they aren’t thinking about taking the right medications or going to an appointment,” he stated. “Sometimes you have to treat the most acute pain the patient is experiencing – even if the pain is a social determinant – before the treatment for a medical condition can be effective.”

"Through this non-clinical referral resource platform, care managers are able to understand at-risk populations and connect individuals to resources in the community to address social vulnerabilities."

Dr. Tanuj Gupta, Cerner

Medical care accounts for only 10-20% of the modifiable contributors to health outcomes, so addressing the remaining 80%, i.e. the behavioral and social determinants that negatively impact health, is where actions can really make a difference, he added.

“These social determinants are true impediments to health, with many variables that can be tuned to improve not only how you impact an individual’s well-being, but how you systematically improve the health of an entire population,” he explained. “This is especially true for challenged populations that are costly to manage.”

Because these factors are such a big part of the lives of these challenged populations, healthcare organizations cannot effectively treat them without treating social determinants in a real way alongside medical treatment, he said.

Being able to address real issues that undermine quality medical care and unequivocally have an impact on population health is why this new era of social determinants of health is so exciting, he said.

What vendors’ systems do with SDOH

It’s clear social determinants are important to the future of effective population health management. So what are population health IT vendors doing today to ensure their technologies incorporate and deploy SDOH data?

“Cerner has developed screening tools for providers to collect social determinants of health data,” said Gupta of Cerner. “Screening tools can be self-administered in a portal or via a clinical or non-clinical staff member in the EHR. The clinician can use the tools and the data they collect to better communicate with the patient and work to resolve issues like food insecurity, transportation, housing and other social determinants of health.”

The Cerner population health platform, HealtheIntent, is able to collect and analyze client data, including social determinants of health information, to help healthcare organizations know and predict what will happen within their populations and engage the person to take action.

“Cerner also has enabled social service directory services to integrate with our platform in order to provide ways for health systems to broaden their options for referrals to social service providers,” Gupta explained. “Through this non-clinical referral resource platform, care managers are able to understand at-risk populations and connect individuals to resources in the community to address social vulnerabilities.”

This can include resources and offerings such as housing, transportation, financial support, meals and more. Care managers are able to track patients and ensure they are receiving the support that has been provided to them.

SDOH are fundamental to patient care

GSI Health believes the idea of extending care to treat the whole person by enabling social determinants to be a full part of a patient’s care is not just additive to medical care but fundamental, said Jones.

“Therefore, addressing social determinants is ubiquitous in all we do – in how we bring together medical, behavioral and social service providers across the community to collaborate as teams with integrated workflows, include behavioral and social determinants in the care plan, collect and report on data, and integrate and share information across organizations,” he said.

"As value-based reimbursement increases in prevalence, health systems are inclined to better understand all attributed patients, including their social barriers that could impact health."

Dr. Joseph Siemienczuk, Enli Health Intelligence

The GSI Health platform is designed not just for one organization to use, but to bring community-based organizations that address social determinants onto a shared platform with the medical team to collaborate with transparency across the team.

“Our technology expands the traditional scope of care coordination by enabling the types of users that address SDOH to work shoulder-to-shoulder with medical providers as full-fledged care team members, using tools that are appropriate for the work they do and sharing information on what happens when the patient leaves the medical facility,” Jones said.

The platform enables collaborative workflows across diverse settings, with configurable program-specific actions to drive care management consistently across organizations so that the social determinant work being performed is transparent across the team and all team members have the up-to-the-minute information they need to be effective, he added.

“Our care management platform also provides insight into how your care management processes influence your results so that you know which activities have the most impact on your population,” he explained. “We look beyond traditional data sources like EHRs and claims and analyze care management activities that impact care, cost, quality and utilization.”

Integrating and analyzing information across all community-based partners provides insights into how processes are working and how behavioral health and social determinants impact a population and the bottom line so one can understand what’s moving the needle and tune one’s activities to improve one’s outcomes, Jones said.

Structured SDOH data capture

At the patient level, Enli Health enables structured SDOH data capture through its CareManager care plan dashboard that is embedded in the EHR or accessible in a web page, said Siemienczuk.

“Enli leverages the CPC+ SDOH assessment, and additionally allows configurable mapping for PRAPARE and other common SDOH assessment types,” he explained. “The assessment logic assigns a risk status, which is surfaced in the care plan dashboard to aid decision making, and also used to drive workflows in Enli’s care coordination application, Central Worklist.”

At the population level, the CareManager social determinants module allows users to risk stratify on specific SDOH measures and overdue assessments. Cohorts can be exported to out-of-the-box or customizable workflow programs in the Central Worklist care coordination application. Integrated reporting capabilities include CPC+ and LOINC code push, he added.

Using the SDOH data

Each of the vendors’ pop health IT has similar outcomes for users incorporating SDOH data. Users see and use a variety of data.

“We have reimagined population health IT to fundamentally incorporate social determinants, opening up our context to account for the delivery of all care, not just medical care,” said Jones of GSI Health. “Our technology can help you identify and separate socially complex populations from medically complex, and enable an orchestration of care around prescribed workflows to address all issues including social determinants of health.”

"People tend to rationalize social determinants of health first in their hierarchy of needs, so if people are worried about where they’re going to sleep, they aren’t thinking about taking the right medications or going to an appointment."

LeRoy Jones, GSI Health

This ensures that each care team member has what they need to treat the right people at the right time with the right actions, improving how they deliver care to these challenged populations, he added.

“All users of our technology, including social service providers, are full-fledged teammates and able to contribute the benefit of their expertise,” he continued. “Each team member sees what is germane to them, organized in a way that is relevant, instead of being forced into a different paradigm such as a medical record and having to dig through notes to find the information they need.”

The entire care team has transparency into what is being done by each organization to mitigate these issues, and how successful each strategy is, he said. The technology can be configured for the specific social determinants that are important to a population so that one can identify the right socially complex cohorts that need additional support and enroll them into the right programs according to the organization’s business model, he said.

“To help you improve your model of care, our technology includes reporting and dashboards that are organized around social determinants of health, enabling you to identify what social issues impact utilization and cost the most across all your partners and the system as a whole,” Jones explained.

“For example, we offer a care management outcomes dashboard that enables clients to understand housing security for their population, highlighting issues such as the percent that are homeless, how long they have been homeless, and more.”

As a result, providers are able to use the technology to evaluate both processes and outcomes so they can tune their activities to make them more effective, he added. By optimizing the work, the outcomes will be better, he contended.

Right in the workflow

Providers will be able to see social determinants of health data for individual patients and populations directly in the workflow, said Gupta of Cerner.

“By having this data incorporated, providers are supported with a fuller picture of a person’s overall health, including outside factors that may affect their ability to get better and stay healthy,” he said.

“Providers can use this to tailor how they handle care for each patient,” he added. “For patients whose conditions are similar on paper, providers can use social determinants of health to see if certain patients may need additional help or intervention to increase compliance with treatment plans.”

Cerner’s SDOH-oriented technology is designed to help healthcare organizations manage problems related to health, not just disease, Gupta said.

“Providers can now also refer patients to a wide variety of social service providers through the HealtheIntent platform in order to help patients have both their medical and social determinant needs addressed,” he said.

At the patient level, overdue SDOH assessments and high-risk areas are surfaced to providers through the CareManager care plan dashboard, said Siemienczuk of Enli Health Intelligence.

“Ensuring up-to-date assessments is a measure of some commercial and governmental reimbursement programs,” he explained. “Presenting information on social risks can enable staff and providers to address priority needs during a patient encounter.”

At the population level, the CareManager social determinants module enables filtering on risk and assessment status. SDOH factors can be combined with clinical risk factors to better target and individualize interventions. Identified priority cohorts can be automatically exported to a Central Worklist care coordination workflow that orchestrates tasks and actions among members of the core and extended care team.

The results of having electronic SDOH data

Vendors’ population health IT that incorporates SDOH data directly affects patient care. Having SDOH data in an electronic format is meaningful to caregivers.

Many of the more forward-looking healthcare organizations are attempting to increase their involvement with social influences inside the geographical area they may primarily operate. For hospitals and health systems, that means bringing in more people with varying areas of expertise.

“Providers are using social determinants of health data to execute on public health initiatives that they haven’t traditionally considered,” said Gupta of Cerner. “Some healthcare organizations are expanding the care team to not only include the physician but also care managers, social workers, family members and even medical legal aids who can work on behalf of patients that need some assistance.”

SDOH data adds pragmatism to a patient’s personalized care pathway by incorporating the non-medical factors that impact health outcomes, said Siemienczuk of Enli Health Intelligence. Information provided on the local food bank and assignment of a caseworker to assist with housing placement are examples of possible uses, he added.

The whole-person care approach

A whole-person care approach that leverages SDOH data in electronic format helps care teams identify non-medical issues that impact the patient and work on those issues alongside medical care so that the patient receives more comprehensive care.

“Our platform enables care teams to identify issues and implement client-configured, standardized interventions that connects patients to the right type of care,” said Jones of GSI Health. “This enables providers to function at the top of their licenses, eliminating overlap and ensuring that each member of the integrated team does what they are trained to do.”

Prescriptive programs, workflows and guidelines ensure that everybody is working together rather than implementing divergent protocols within their silos, he added.

“The trick is how to figure out if those efforts were successful,” he explained. “You can’t fix what you can’t measure, and you can’t measure if you can’t capture data in a consistent way. One of the values our technology brings is the ability to standardize the representation of those SDOH factors through consistent assessments and data elements.”

This enables a new generation of analytics that helps one understand the impact of social determinants on an entire population so that one can proactively address SDOH, he said.

How social issues impact cost and outcomes

“For example, Care Compass Network in New York uses our technology to capture social determinants of health information, and shares it with another system to adjust risk scores,” Jones noted. “By calling out the issues facing socially complex populations, you can drill down to how those social issues impact cost and outcomes, rather than analyzing the issues as part of a broader population. This capability is fundamental to improving the circumstances of more challenged populations.”

GSI Health clients are achieving results by addressing social determinants: While each organization measures success differently, the technology has empowered clients to work more efficiently and effectively to reduce readmissions and the total cost of care, reduce emergency department usage as the first point of entry, increase the use of primary care, improve connectivity to services that address social determinants, and improve transitional care for more vulnerable populations, Jones said.

“One example of the success of this approach is how Pathway Home, a Care Transition Program of Coordinated Behavioral Care in New York, successfully transitioned patients to function in the community through a program focusing on patient support systems and community ties during the critical period following discharge,” he said. “A key result is that 94% of their participants stayed out of the hospital during their first 30 days back in the community, compared with an 87% psychiatric hospitalization readmission rate in those same 30 days.”